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Chapter: Essentials of Psychiatry: Anxiety Disorders: Panic Disorder With and Without Agoraphobia

Panic Disorder: Pharmacotherapies

Controlled studies show that effective anti-panic medications include tricyclic antidepressants (e.g., imipramine), monoamine oxidase inhibitors (MAOIs; e.g., phenelzine), high-potency ben-zodiazepines (e.g., alprazolam) and SSRIs (e.g., fluvoxamine).

Pharmacotherapies

 

Controlled studies show that effective anti-panic medications include tricyclic antidepressants (e.g., imipramine), monoamine oxidase inhibitors (MAOIs; e.g., phenelzine), high-potency ben-zodiazepines (e.g., alprazolam) and SSRIs (e.g., fluvoxamine). These treatments have broadly similar efficacy, although there is some evidence that SSRIs tend to be most effective. The classes of medication differ in their side effects and their contraindica-tions. Anticholinergic effects (e.g., blurred vision, dry mouth) are common problems with tricyclics. They are also contraindicated in patients with particular comorbid cardiac disorders. Dietary restrictions (i.e., abstaining from foods containing tyramine) are a limitation of many MAOIs. Sedation, impaired motor coordination and addiction are concerns with benzodiazepines.

 

When effi cacy and side effects are considered together, SSRIs emerge as the most promising drug treatments for panic disorder. However, even SSRIs have side effects, with the most problematic being a short-term increase in arousal-related sensations. To overcome this problem, SSRIs can be started at a low dose (e.g., 5–10 mg/d for paroxetine; 12.5–25 mg/d for ser-traline) and then increased gradually (e.g., up to 10–50 mg/d for paroxetine; up to 25–200 mg/d for sertraline). The choice of SSRI is determined on the basis of several factors, including side ef-fects, patient preference and the patient’s history of responding (or not responding) to particular agents.

 

For drug refractory patients, or patients who are un-able to tolerate SSRI side effects, combination medications aresometimes used. For example, SSRIs can be augmented with benzodiazepines. The latter are used to dampen the side effects of SSRIs. Despite some positive preliminary reports supporting this strategy, its value in the treatment of panic disorder remains to be properly evaluated. An alternative strategy is to change the patient’s medication. Some of the newer, nonSSRI antidepressants could be considered, such as venlafaxine, nefazodone, buproprion, duloxetine, or gabapentin. A concern with using these newer med-ications to treat panic disorder is that there are few data to guide the clinician. Another approach to the drug refractory patient is to use a psychosocial treatment such as cognitive–behavioral ther-apy (CBT), as an alternative or adjunctive intervention.

 

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Essentials of Psychiatry: Anxiety Disorders: Panic Disorder With and Without Agoraphobia : Panic Disorder: Pharmacotherapies |


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